This inspection took place on 1 and 2 August 2017 and was unannounced.

Acacia House provides accommodation for up to 47 people with nursing and personal care needs. There were 41 people living at the service at the time of our inspection, although one person was in hospital. Some people had complex needs and required continual nursing care and support, including end of life care. Others were living with dementia and because of physical frailty or medical conditions, needed assistance with person care and moving around the home safely.

The service is an old house with a new extension on the ground floor. There are 44 rooms of which three can accommodate two people. The lower floor provides a dining room and three lounges as well as level access to the secure and well maintained gardens. Access to the upper floor is by a passenger lift and two staircases. There is onsite parking available.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Registered persons have a legal responsibility for meeting the requirements of the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Acacia House was last inspected in May 2016 when the service was rated overall as ‘Requires Improvement.’ This was because people did not always receive their medicines in accordance with their prescriptions or medical guidance and some people’s wishes about their end of life care were not always recorded. People were not always involved in the decisions about their care and treatment and, if people or their representatives were involved in care decisions, the process was not always recorded. Quality monitoring was not always effective; shortfalls in people’s care and treatment had not been identified by the provider or senior managers and people and staff were not always consulted or involved in the running of the service. This inspection found improvement had been made.

Staff followed correct and appropriate procedures in the storage and dispensing of medicines. People were supported in a safe environment and risks identified for people were managed in a way that enabled people to live as independent a life as possible. People were supported to maintain good health and attended appointments and check-ups. Health needs were kept under review and appropriate referrals were made when required.

An adequate system to recruit new staff was in place and made sure staff employed to support people were fit and suitable to be working at the service. There were sufficient numbers of staff on duty to make sure people were safe and received the care and support that they needed.

Staff had completed induction training when they first started work at the service. Staff were supported during their induction, monitored and assessed to check that they had gained the right skills and knowledge to support people in a way that met their needs. Staff continued to receive training and support. There were staff meetings, staff could discuss any issues and share new ideas with their colleagues, to improve people’s care and lives.

The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS). The manager and staff showed that they understood their responsibilities under the Mental Capacity Act 2005 and DoLS and the least restrictive measures were in place to keep people safe and ensure they were not deprived of their liberty unnecessarily. Staff continued to seek consent of people for their everyday care and support needs.

People were protected from the risk of abuse because staff had received safeguarding training and were aware of how to recognise and report safeguarding concerns. Staff knew about whistle blowing and were confident they could raise any concerns with the provider or outside agencies if needed.

The care and support needs of each person were different and their c

This inspection took place on 26 and 27 May 2016 and was unannounced. The service was previously inspected in June 2014 and no breaches in the legal requirements were found.

Acacia House provides nursing and personal care for up to 47 older people, some of whom may be living with dementia and other complex health conditions. The service is an old house with a new extension on the ground floor. There are 44 rooms of which 3 can accommodate 2 people. The lower floor contains a dining room, and three lounges. The upper floor, which is traversed by narrow corridors, is accessed by a lift and two staircases. People’s rooms were personalised by items of furniture and personal items. The older part of the house retains its original features and the lounge area on ground level leads out into a secure garden space. At the time of this inspection there were 43 people using the service.

There is a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons.' Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Quality monitoring was not always effective. Shortfalls in people’s care and treatment had not been identified by the provider or senior managers. People and staff were not always consulted or involved in the running of the service.

People did not always receive their medicines in accordance with their prescriptions or medical guidance. People’s wishes in relation to the end of their lives were not always recorded.

People were not always involved in the decisions about their care and treatment. If people or their representatives were involved in care decisions the process was not always recorded.

People had a range of activities which they could chose to participate in. However, people who were at risk of social isolation were not offered a choice of activities and had limited opportunities to spend time with others.

Staff understood their responsibility in protecting people from the risk of harm. Sufficient staff were available to meet people's needs but there was an ongoing need to recruit new staff. Safe recruitment practices meant that suitable staff were employed to work with people. Staff had received training to enable them to provide the right care and support to people.

People received care and support from staff who were caring and ensured their dignity and privacy was respected.

Risk assessments and support plans had been developed to give person centred care. Staff had the relevant information about how to minimise identified risks to ensure people were supported in a safe way. People had access to a range of healthcare professionals when they needed them to support their care and treatment.

People knew how to complain and would be happy to speak with a manager if they had any concerns. Families and staff felt they could raise any concerns or issues they may have with the registered manager, who they said was approachable. People felt their views and experiences were listened to.

The provider had notified us of the outcome of referrals which they had made to the supervisory body for authority to deprive a person of their liberty.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have asked the provider to take at the end of this report.

The inspection was carried out by one Inspector over seven hours; and by a Pharmacy Inspector who stayed for three hours and assessed the management of medicines. We followed up outcomes in the home which had been identified as concerns during the previous inspection; and looked at some additional outcomes.

During the visit we talked with six people who were living in the home, and observed staff carrying out care duties. We talked with eleven staff and met other staff briefly; and talked with one relative, four visitors, and a visiting health professional. We also talked with a student nurse who was on a work placement in the home. The manager and deputy manager were present throughout the inspection and assisted us by providing documentation for us to view.

We looked at the answers to five questions: Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

Is the service safe?

We saw that the premises were visibly clean in all areas and were satisfactorily maintained. A new wing had been built, and was sectioned off until it had been registered for use. This was to prevent people from wandering into this area where staff were not present.

We inspected medication management and found that appropriate procedures were in place to ensure that people received the right medicines at the right time, with the support of trained nursing staff.

We found that the company had comprehensive procedures in place to check that people had consented to the care and treatment provided for them. People who lacked the mental capacity to make decisions about where they lived or the care that they needed had been appropriately supported by their family members or advocates, and by health and social care professionals, to make decisions on their behalf and in their best interests. The manager and staff showed that they understood their responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). This meant that people were appropriately supported according to their levels of mental capacity.

Is the service effective?

We found that people’s care plans provided clear details of their care and treatment so that staff could give effective care. The care plans included individual needs assessments, and people’s preferences in regards to their care. We saw that people or their representatives had been involved in all aspects of their care planning.

We found that the staff liaised appropriately with other health and social care professionals to provide people with additional care or treatment.

The home provided people with a variety of food and drinks to meet their different nutritional needs. People said that the food was good, and they could choose alternatives to the two main dishes provided each day if they preferred something different.

Staff had been trained in required subjects such as health and safety, moving and handling, infection control and safeguarding vulnerable adults. We saw that this training was kept up to date, and additional training courses were provided so that staff could develop their skills and their knowledge in line with people’s needs.

Is the service caring?

We saw that the home had a relaxed atmosphere, and people were supported to sit where they wanted to, and to take part in activities that they preferred. People’s comments included, “The staff look after me extremely well. Everyone is very nice and friendly”; and “I think it is excellent here, staff are very caring.”

The home provided a range of activities. We saw that these were carried on throughout the day, and included individual time with staff, and group activities. People were enabled to go out for walks, or sit in the lounges or the gardens; or could sit in their own rooms, depending on their choice. Activities were sometimes carried out during the evenings as well.

We saw that some people needed assistance with eating and drinking. The staff sat alongside people and engaged them in conversation during this time, so as to make the meal a more pleasant experience. We saw that staff did not rush people.

We viewed responses that people had given to questions in the last survey, which had been carried out by the home to assess people's experiences. One of the questions was “Do staff treat you with respect and dignity?”, to which one hundred per cent of people had responded “Yes.”

Is the service responsive?

The service had an arrangement with the local GP surgery for routine weekly visits to the home. We saw that nursing staff recognised when people needed to see the doctor and ensured they were seen as needed. Referrals were made to other health and social care professionals as necessary.

Care staff and activities staff were aware of people who were bed bound and needed to stay in their rooms. They carried out a minimum of hourly checks during the day and the night to ensure people had the care that they needed. We found that staff spent individual time with people in their own rooms in order to prevent social isolation.

People that we talked with said that if they had any worries or concerns they would talk to any of the staff. They were confident that the staff would take appropriate action to deal with their concerns, or would speak to the nurses or the manager or deputy manager to ensure the necessary action was taken.

Is the service well-led?

The company had systems in place for the on-going monitoring of the home. This included weekly and monthly audits for different aspects of care in the home such as care planning audits and medication audits. Other audits for the environment were carried out, such as health and safety checks, fire system checks and recording of water temperatures.

We saw that the manager and deputy manager had a visible presence in the home, and people knew them well. Staff said that they found the management structure to be supportive; and some staff members said they knew some of the senior managers in the company, and could talk to them if they wanted further advice.

We found that people’s comments on surveys were followed up where action was needed. Staff said that they felt able to raise concerns and they were listened to. For example, staff said they would be able to discuss the implications of having six extra beds which were soon due to be registered, as this could mean some changes in staffing numbers and deployment.

At this inspection, there were 34 people living at the service, 30 people required nursing care and 4 people received residential care. The people living at the service were elderly, some had very limited mobility and dementia.

We spoke with eight people who used the service. People told us that they were happy living there and that the staff are kind. One person said "I am very comfortable living here". Another person commented “I have no complaints”, although another person told us "There are not sufficient staff".

Our last inspection of 5 September 2013 found that accurate records were not kept about the care and treatment provided for people using the service.

At this inspection we found that the service had not addressed the concerns we had previously raised about record keeping. People were not protected against risks of unsafe or inappropriate care and treatment arising from a lack of proper records.

We found that people were not protected against the risks associated with unsafe use and management of medicines, because some people did not receive medication when they were supposed to.

Proper steps were not taken to ensure that people were protected against the risks of receiving care or treatment that is inappropriate or unsafe. We found that some people had not received the care and support that their care plans said they needed.

We found that there were not always enough staff on duty to meet people's needs.

We found that complaints had been recorded, investigated and responded to.

At the time of our inspection, there were 36 people living at the service.

We spoke with most of the people who used the service and some visitors. People told us they were happy with the care and support they received. Their comments reflected the kindness and care provided by staff, but also reflected how busy people perceived the staff to be.

One person said “Top marks, I have never been a happier chap” and “I feel well looked after”. However, other comments included “I would like to go outside, but sometimes staff are too busy to take me”. One visitor told us “I am really happy with the care provided”, but another visitor commented “(relative’s name) didn’t have their initial needs assessed before they were admitted, we felt quite surprised and concerned”.

Care plans were individual, they contained people's choices and preferences and appropriate risk assessments were in place. However, some records contained health plans that were no longer relevant, but were not noted as such.

All the people we spoke with told us that they felt safe and that they would know what to do if they were worried or concerned.

People said that they trusted the staff. They felt that the staff had a good understanding of their needs as well as the skills and knowledge needed to effectively support them.

There were a range of checks and audits in place to monitor the quality and safety of the service provided.

We used a number of different methods to help us understand the experiences of people using the service, as some people had complex needs, this meant they were not always able to tell us about their experiences themselves. As well as speaking with people we looked around the service and observed how people interacted with staff, we spoke with staff, visitors and the registered manager. We also read documents including care plans and health records.

We spoke with five people who used the service and visiting relatives. People told us that they found Acacia House provided a good quality of service. Comments made included “I am very happy, my room is comfortable and kept clean and I like the choice of food”. Another person told us “The staff are good, they come quickly when I buzz them, I find that reassuring”.

When we looked around the service we saw that people were offered choices and their dignity and independence was respected. People generally spoke highly of the staff, some people said occasionally staff needed reminding about particular requirements or preferences, however, they felt that their views and opinions were taken into account when planning care and support. People said they had opportunities to take part in activities and enjoyed the events that the service arranged.

During our inspection we noted a few minor concerns that the provider may find useful to consider. They relate to aspects of cleanliness and the wishes of people who used the service.

The people we spoke to about Acacia House generally liked living there. People spoke highly of the staff and home manager, and felt that their views and opinions were taken seriously. We heard positive comments about the food at Acacia House, including, ”The food is a lot better here than the last place, there are two choices every day and they ask what you want”.

A general view held by the people who lived at Acacia House and their relatives seemed to be the lack of time staff had to sit and chat to people. One relative said ”The carers don’t chat because they haven’t got much time”. Everyone we spoke to agreed that the staff were helpful and kind. One person told us ”All the girls are very, very nice” and ”Helpers are very nice”.